Download PDF
Exp Clin Endocrinol Diabetes 2002; 110(7): 364-369
DOI: 10.1055/s-2002-34995
Case Report

© Johann Ambrosius Barth

Autonomic Failure Mimicing Dopamine Agonist Induced Vertigo in a Patient With Macroprolactinoma

L. Seiler1 , S. Braune2 , K. Borm1 , C. Magerkurth2 , J. Talazko3 , T. Peters4 , M. Reincke1
  • 1 Department of Internal Medicine II, University of Freiburg, Germany
  • 2 Department of Neurology, University of Freiburg, Germany
  • 3 Department of Radiology, University of Freiburg, Germany
  • 4 Department of Internal Medicine, Claraspital, Basel, Switzerland
Further Information

Publication History

received 19 November 01 first decision 23 March 02

accepted 27 March 02

Publication Date:
24 October 2002 (online)

Also available at
    Permissions and Reprints

Summary

A 68-year-old man presented with general fatigue, increasing adynamia, weakness, vertigo and recurrent syncope. Six weeks earlier the diagnosis of a macroprolactinoma had been established based on a greatly elevated prolactin concentration (161 170 μU/l) and MR-evidence of a 3.5 cm measuring pituitary mass. The patient had been started on cabergoline (1.5 mg weekly). Orthostatic hypotension due to the dopamine agonist was considered very likely and carbergoline therapy was stopped. However, there was no relief of the symptoms and further syncopes followed. Testing of blood pressure and heart rate regulation, selective testing of postganglionic cardiac neurons with [123J] metaiodobenzylguanidine scintigraphy provided evidence of grossly impaired neurogenic cardiovascular regulation due to failure of postganglionic efferent sympathetic activity. This is characteristic for pure autonomic failure. The patient was treated symptomatically with high fluid intake, compression stockings, fludrohydrocortisone (0.1 mg o.d.s.), piroxicam (20 mg o.d.s.) and etilephrin (10 mg q.d.s.), which enabled him to cope with daily activities without syncope. This case shows that vertigo in a patient with macroprolactinoma is not always related to drug therapy but may be related to other causes.

Key words:

Orthostatic hypotension - autonomic failure - prolactinoma

References

  • 1 American Autonomic Society and American Academy of Neurology . Consensus statement on the definition of orthostatic hypotension, pure autonomic failure and multiple system atrophy.  Clin Autonomic Res. 1996;  6 125-126
    PubMedSearch in Google Scholar
  • 2 Arai K, Kato N, Kashiwado K, Hattori T. Pure autonomic failure in association with human alpha-synucleinopathy.  Neuroscience Letters. 296 (2-3) 171-173 2000; 
    CrossrefPubMedSearch in Google Scholar
  • 3 Becker K, Keuser R, Weber M, Steffen H M. Autonomic failure as the cause of vertigo and prolactinoma.  Med Klin. 90 (7) 398-402 1995; 
    PubMedSearch in Google Scholar
  • 4 Bernard A, Koch J, Vetter W. Prevalence of hypotension and symptomatic, orthostatic dysregulation in a patient sample of a medical polyclinic.  Schweiz Rundsch Med Prax. 88 (13) 547-558 1999; 
    PubMedSearch in Google Scholar
  • 5 Colao A, Annunziato L, Lombardi G. Treatment of prolactinoma.  Ann Med. 30 (5) 452-459 1998; 
    CrossrefPubMedSearch in Google Scholar
  • 6 Dae M W, O'Connell J W, Botvinick E H. Scintigraphic assessment of regional cardiac adrenergic innervation.  Circulation. 79 (3) 534-644 1989; 
    PubMedSearch in Google Scholar
  • 7 Esler M, Jackman G, Kelleher D, Skewa H, Jennings G, Bobik A, Korner P. Norepinephrine kinetics in patients with idiopathic autonomic insufficiency.  Circ Res. 1980;  46 I47-I48
    PubMedSearch in Google Scholar
  • 8 Gasnier B, Roisin M P, Scherman D. Uptake of meta-iodobenzylguanidine by bovine chromaffin granule membranes.  Mol Pharmacol. 29 (3) 275-280 1986; 
    PubMedSearch in Google Scholar
  • 9 Glowniak J V, Kilty J E, Amara S G. Evaluation of metaiodobenzylguanidine uptake by the norepinephrine, dopamine, and serotonin transporters.  J Nucl Med. 1993;  34 114-116
    PubMedSearch in Google Scholar
  • 10 Grubb B P, Klingenleben T. Syndromes of autonomic insufficiency associated with orthostatic intolerance: classification, diagnostic and therapeutic approach.  Z Kardiol. 1999;  88 541-549
    CrossrefPubMedSearch in Google Scholar
  • 11 Hague K, Lento P, Morgello S, Caro S, Kaufmann H. The distribution of Lewy bodies in pure autonomic failure: autopsy findings and review of the literature.  Acta Neuropathol. 1997;  94 192-196
    CrossrefPubMedSearch in Google Scholar
  • 12 Hale W A, Chamblis M L. Should primary care patients be screened for orthostatic hypotension?.  J Fam Pract. 48 (7) 547-552 1999; 
    PubMedSearch in Google Scholar
  • 13 Jaques S, Tobes M C, Sisson J C. Sodium dependency of uptake of norepinephrine and m-iodobenzylguanidine into cultured human pheochromocytoma cells: evidence of uptake-one.  Cancer Res. 1987;  47 3920-3928
    PubMedSearch in Google Scholar
  • 14 Jaques S, Tobes M C. Comparison of the secretory mechanisms of meta-iodobenzylguanidine (MIBG) and norepinephrine (NE) from the cultured bovine adrenomedullary cells.  J Nucl Med. 1985;  26 17
    PubMedSearch in Google Scholar
  • 15 Kreiner G, Wolzt M, Fasching P. Myocardial m[123I]iodobenzylguanidine scintigraphy for the assessment of adrenergic cardiac innervation in patients with IDDM: Comparison with cardiovascular reflex tests and relationship to left ventricular function.  Diabetes. 44 (5) 543-549 1995; 
    PubMedSearch in Google Scholar
  • 16 Langer A, Freeman M R, Josse R G. Metaiodobenzylguanidine imaging in diabetes mellitus: assessment of cardiac sympathetic denervation and its relation to autonomic dysfunction and silent myocardial ischemia.  J Am Coll Cardiol. 25 (3) 610-618 1995; 
    CrossrefPubMedSearch in Google Scholar
  • 17 Mathias C J, Mallipeddi R, Bleasdale-Barr K. Symptoms associated with orthostatic hypotension in pure autonomic failure and in multiple system atrophy.  J Neurol. 1999;  246 893-898
    CrossrefPubMedSearch in Google Scholar
  • 18 Mathias C J. Orthostatic hypotension: Causes, mechanism, and influencing factors.  Neurology. 1995;  45 S6-S11
    PubMedSearch in Google Scholar
  • 19 Matthews M R. Assessing the peripheral ganglia in autonomic failure. In: Bannister R (ed). Autonomic failure, Second Edition Oxford Medical Publications, Oxford 1988: 521-543
    Search in Google Scholar
  • 20 Meredith I T, Eisenhofer G, Lambert G W, Jennings G L, Thompson J, Esler M D. Plasma norepinephrine responses to head-up tilt are misleading in autonomic failure.  Hypertension. 1992;  19 628-633
    PubMedSearch in Google Scholar
  • 21 Oppenheimer D. Neuropathology of autonomic failure. In: Bannister R (ed). Autonomic Failure, Second Edition Oxford Medical Publications, Oxford 1988: 451-463
    Search in Google Scholar
  • 22 Polinsky R J, Nee L E. Autonomic failure: Nosology, clinical evolution, and prognosis.  Ann Neurol. 1989;  26 121
    CrossrefPubMedSearch in Google Scholar
  • 23 Polinsky R J, Kopin I J, Ebert M H, Weise V. Pharmacological distinction of different orthostatic hypotension syndromes.  Neurology. 1981;  31 1-7
    PubMedSearch in Google Scholar
  • 24 Robertson D, Robertson R M. Causes of chronic orthostatic hypotension.  Arch Int Med. 1994;  154 1620-1624
    PubMedSearch in Google Scholar
  • 25 Schnell O, Kirsch C M, Stemplinger J. Scintigraphic evidence for cardiac sympathetic dysinnervation in long-term IDDM patients with and without ECG-based autonomic neuropathy.  Diabetologica. 38 (11) 1345-1352 1995; 
    CrossrefPubMedSearch in Google Scholar
  • 26 Silke B, Spiers J P, Boyd S, Graham E, McParland G, Scott M E. Evaluation of non-invasive blood pressure measurement by the Finapres method at rest and during dynamic exercise in subjects with cardiovascular insufficiency.  Clin Autonomic Res. 1994;  4 49-56
    PubMedSearch in Google Scholar
  • 27 Sisson J C, Wieland D M, Sherman P. Metaiodobenzylguanidine as an index of the adrenergic nervous system integrity and function.  J Nucl Med. 28 (10) 1620-1624 1987; 
    PubMedSearch in Google Scholar
  • 28 Sisson J C, Shapiro B, Meyers L. Metaiodobenzylguanidine to map scintigraphically the adrenergic nervous system in man.  J Nucl Med. 28 (10) 1625-1636 1987; 
    PubMedSearch in Google Scholar
  • 29 Sisson J C, Lynch J J, Johnson J. Scintigraphic detection of regional disruption of adrenergic neurons in the heart.  Am Heart J. 1988;  116 67-76
    CrossrefPubMedSearch in Google Scholar
  • 30 Van Ingelghem E, Van Zandijcke M, Lammens M. Pure autonomic failure: a new case with clinical, biochemical, and necropsy data.  J Neurol Neurosurg Psychiatry. 1994;  57 745-747
    CrossrefPubMedSearch in Google Scholar
  • 31 Wieland D M, Mangner T J, Inbasekaran M N. Adrenal medulla imaging agents: a structure-distribution relationship study of radiolabeled aralkylguanidines.  J Med Chem. 1984;  27 149-155
    CrossrefPubMedSearch in Google Scholar
  • 32 Ziegler M G, Lake C R, Kopin I J. The sympathetic-nervous-system defect in primary orthostatic hypotension.  N Engl J Med. 1977;  296 293-297
    PubMedSearch in Google Scholar

Dr. Lysann Seiler

Department of Internal Medicine II

Hugstetter Strasse 55

79106 Freiburg

Germany

Phone: + 49-761-2703401

Fax: + 49-761-2703413

Email: seiler@medizin.ukl.uni-freiburg.de